More pain sites over time = greater risk of work disability

It struck me today, as I spent a little time with two people who have been returned to Pain Management Centre for a review of their progress, that something we don’t do very well is help people distinguish between an acute or new problem and what might be a flare-up of the old chronic problem. And by ‘we’ I mean all health providers.

Ok, so that the problem is there is not really so surprising – after all, helping clinicians work out that chronic pain doesn’t respond to acute pain management is quite a change of focus (from short-term cure to long-term management), but I guess I hadn’t really thought through how to help people deal with new pain problems as they arise.

Let me illustrate what I mean. Gary (not his real name, and other details are also disguised to protect privacy) has returned to work after nearly five years since his injury. The original injury was a crush injury to his foot and he was left with a complex regional pain syndrome. For at least the first three years he believed, because he was told by surgeons, that surgery would ‘fix’ the problem – and it was a case of him simply waiting for the surgeons to decide what the best surgical option would be. Unfortunately, his foot pain didn’t respond to surgery and he’s ended up with an arthrodesed ankle and chronic pain. The pain is not resolving – but he is feeling quite confident about how to manage it after completing a pain management programme and with some individual input to help with his mood and return to work planning.

Unfortunately, he’s hurt his knee now. He came off a ladder and landed awkwardly on his knee about five months ago. Initially his GP suggested that he simply wait for it to settle, but Gary had learned from his foot problem that it’s better to get on with moving it – and he didn’t want to risk his return to work planning. So he got a knee brace, had some physiotherapy, and carried on. After about two months, he saw a surgeon who said his knee didn’t need surgery right now although it was a little ‘sloppy’ in the ligaments, so Gary should keep on with his exercises, be ‘careful’ and wait for a while before considering a surgical review.

Now the point of this is that Gary didn’t know whether his knee pain was something he should worry about, or whether it was something he should treat as he does his foot pain – using pain management strategies. I’m picking that he found it hard to know whether he was going to do further damage by using his knee normally (ie what are the risks from using a ‘sloppy’ knee), given that he knows that his foot pain is no longer related to damage.

It seems likely that if someone has a central sensitisation problem, for example, they develop a CRPS, the chance of their nervous system responding similarly to another trauma is quite high. A similar case might be someone who has fibromyalgia, with widespread body pain, and a sensitive nervous system – a person in this situation may also be quite likely to take a long time for post-traumatic aches and pains to settle down.

BUT I don’t think I routinely mention this to people I’ve worked with.

What might the implications be for someone who has a chronic pain problem, and then develops a new, acute pain? Well, given the difficulty we find with treatment providers switching from acute management to chronic management, I think the same old problems are likely to rise. Lots of investigations to work out why the pain isn’t settling as it ‘should’ (and as it would if there wasn’t an underlying central nervous system sensitivity), and lots of passive treatments to reduce the pain – but if the pain isn’t directly related to the acute tissue disruption, then it’s unlikely to respond to these treatments – and I’m sure yet more investigations and treatments are tried.

Let’s take a step back and look at whether there are differences between acute management and chronic management.

In acute management, for the majority of problems (and I’m racking my brain to think of one actually) we ask people to start doing things normally as soon as possible – pain doesn’t have to be completely gone before we encourage people to get moving. In chronic pain management, we ask people to do things despite pain.

In acute management, we encourage a ‘start low and go slow’ approach to increasing activity. We do the same in chronic pain management.

In chronic pain management, we recognise the pain is a stressor, and that there is a relationship between having pain and physiological arousal. In acute pain, the same phenomenon occurs.

So is the main difference is in determining the end goal of treatment? – in acute pain management, we are relatively certain that pain will eventually subside. In chronic pain management, we are relatively sure that pain will persist. So we are really looking in both cases at encouraging a focus on function – but in acute pain, the ‘end point’ is often reaching when the pain reduces.

I wonder whether we need to focus on using the same cognitive behavioural approach to self managing many acute problems that we use for chronic pain. And maybe we should consider whether we need to advise people who have chronic pain of their susceptibility to pain in other parts of their body and manage that pain accordingly. It might just save an awful lot of money on treatments for ‘acute on chronic’ low back pain (just what is that, really?), or for ‘acute back pain’ when the low back pain has never really gone away…

I included this study from Norway, because I think it illustrates something that we observe very often. I call it ‘recycling’, but other people call it ‘frequent fliers’ – people who have pain in more than one part of their body are more likely, at least in this study, to eventually move onto Disability payments, and stop work.

I don’t think this is simply the effect of a person having trouble coping with the additional burden of pain – I think it’s much more about a systems problem. If the participants in this study engage with the health system each time they develop a new pain site, the chance of their encountering another provider who follows an acute pain management model (with all that can entail when problems fail to resolve) is pretty high. And with each new encounter with a health provider challenging their own belief in their ability to self manage, these people have a real struggle to remain confident that they can do things despite their various pain.

For this week I’m going to focus on follow-up and effective use of the health care system – care to join me on this journey? If you do, you can subscribe using the RSS feed link above, or you can just bookmark this page and come back. I do write most days during the week, and I do love comments. If you don’t want people to read your comments, you can send them to me via the ‘About’ page which gets sent directly to my email, otherwise they’ll appear on here for others to respond to. I’m looking forward to hearing from you!

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2 comments

I know this is Monday’s post (but exam prep takes precedence).
I just wanted to say how difficult it is (as a person who lives with pain) to decide when something new needs to be check out. But even the fact that I do know my body reacts out of proportion to most injuries now, its very easy to dismiss things as sensitivity reactions when in fact its a broken bone (like I did last year). But then just recently when we thought I had appendicitis its now turned into ‘related to crps and who knows when/if you will stop feeling ill’. How do you decide when its a ‘sensitivity’ issue or in fact something that needs medical attention? I’m forever feeling confused and the fact that people don’t seem to understand chronic pain, I’m forever being told off for not gettting things checked out!

I can only imagine how difficult it must be for you to to try and work out whether to seek medical treatment for a new pain. I think there will be no simple, single answer – and it will probably depend a bit on how intense the pain is and the impact on function. My final criterion would be how long it lasts – neuropathic or centrally-maintained pain will remain, while acute pain will gradually drop off. I would say if a reasonably common cause can’t be identified, and if the management isn’t likely to change, then I’d suggest stopping the search for new mechanisms, stop the investigations and get on to living well. At least that’s what I’ve done in my own case with fibromyalgia. And for me, finding a treatment for my muscle aches and pain even when I know it’s from something I’ve done acutely is fruitless – so I might as well just use my self management strategies!
Oh, and I hope the exams went OK!